Dr. Omorogbe Owens Steven, Director of Planning, Research and Statistics at the Edo State Health Insurance Commission (EDOHIC), in this interview with The Nigerian Observer’s Edward Oseghe, Bill Okonedo and Victory Okonjo, speaks about the challenges, breakthroughs and prospects of the Edo State Health Insurance Scheme (EDOHIS) going forward.
I am Dr. Omorogbe Owens Steven, the Director of Planning, Research and Statistics for the Edo State Health Insurance Commission.
Health Insurance essentially has become a revolutionary health financing mechanism whereby funds or resources can be pooled from several subscribers or contributors to form a source that is a pool or reservoir through which strategic purchasing of effective, qualitative and responsive healthcare can be made.
Interestingly, in this clime, especially with the dwindling economic fortunes of the citizens of the country, health insurance has become even more valued and more pertinent, more integral to improving the quality of life of the residents of the country because it provides financial risk protection. We know that most health emergencies do not give advance notice and because the average citizen might not necessarily possess the financial might to meet their evolving and dynamic needs, this becomes a challenge.
We know that healthcare, even before these global economic vagaries, has been expensive.
Getting the quality of care that one might need at a point in time might be beyond the average resident. So, to tackle that, a pool of funds is brought to the fore that can help pay for the quality of care residents, citizens or subscribers might need at every point in time. We all know from research and our studies that not every subscriber falls ill at the same time. So what that means is that Health Insurance can provide financial risk protection for any subscriber who falls ill within that particular point in time and ensure that he or she can get qualitative healthcare.
All these strategic plans and financial risk protection are thematic areas and critical hallmarks of our drive toward achieving universal health coverage. Universal health coverage entails that every citizen irrespective of their socio-economic, educational, or political status, can receive qualitative healthcare at any point in time without undue financial hardship. That is why health insurance has become one of the main driving forces towards achieving universal health coverage.
At the Edo State Health Insurance Commission, a technical committee was set up in 2017 to draw ways and means of setting up an insurance scheme that will provide risk protection, qualitative healthcare and be dynamic and responsive to the health needs of the population. This culminated in the ascent to law on the 30th of May, 2019, by His Excellency, Gov. Obaseki, for the entrenchment of the law setting up Edo State Health Insurance Commission in the state and after that, a lot of study tours took place to ensure that our protocols and processes are drawn up in consonance with global best practices. Study tours included countries within and outside the continent, as well as other states that started before us, and all this was to elicit the processes and protocols that would best meet the evolving needs of citizens of the state. We also did analysis and carried out various surveys and research modules to find out what those needs are, and suffice to say that on the 1st of July, 2021, access to care began on the EDOHIS, and since then we’ve had a multitude of unending testimonials from enrollees who have enjoyed the impactful, very dynamic and responsive health insurance scheme that has been set up at EDOHIS.
EDOHIS is designed to provide qualitative healthcare for all strata of the population. The Health Plans are designed in such a way that they cut across all socio-economic stratifications, so everyone can get a health plan that is attuned and suited to their economic status. We essentially came up with five distinctive health plans.
The first was the formal sector plan which caters to staff of the state government and appointees, those who earn their salaries directly from the state government. Their premiums are deducted as 1.75% of their gross salary monthly and the government also matches with 1.75% making up 3.5% monthly of their gross salaries, and that serves as their premiums. That’s for the formal sector plan.
The informal sector plan was stratified according to the socioeconomic needs and might of the population into four distinctive plans:
We have what we call the Bronze Plan, which although it is rated at N18,000 yearly as a premium, and the services on that plan are worth N1.8 million.
We have the Silver Plan which is rated at N35, 000 yearly but the services on that plan available to subscribers are worth N2.5 million.
The Gold plan is rated at N68,000 as a premium yearly but the benefits are over N3.5 million.
Then we have the Private Enhanced plan, which is a flagship plan and our most robust plan which is rated at N75, 000 annually but the benefits are worth N4.5 million.
So what this informal sector plan has encouraged, is that artisans and those in the organised private sector will be able to key into any of these plans that they can readily afford. We even went as far as setting up a desk to facilitate installment payments because we know that with the global economic downturn, it might be a bit arduous for the average citizen to cough up some of these sums at ago.
So, we have drawn up mechanisms such as an alligator’s desk, and affiliations with microfinance agencies that can help to collect money in installments from market women and artisans to try and encourage them to key into Health Insurance.
Tertiary Institutions Health Plan:
We also have the Tertiary Institution Health plan which caters to students in higher institutions. As of today, all the students in Ambrose Alli University, Edo State University Uzairue, and Edo State School of Nursing, are all on the plan. Just recently, Igbenedion University has also keyed into the insurance plan to provide health coverage for the students in the institution.
We also have the Equity Plans which are designed, in collaboration with Federal and State Governments, for those who are said to be vulnerable, to be able to get qualitative and responsive healthcare without any financial commitment. The National Health Act of 2014 and the National Health Insurance Authority (NHIA) Act of 2022, have clearly defined vulnerable people as children under 5, the elderly above 65, people living with disabilities, pregnant women, as well as the poorest of the poor. These people are identified, screened and enrolled into our Equity plans and availed of qualitative healthcare free of charge.
The National Health Act of 2014 and NHIA Act of 2022 now make Health Insurance compulsory and since then, any establishment that has at least three staff must be able to provide health insurance for its staff. So keying into that vision, we have encouraged that at the formal sector, all deductions are to be made from source to make the process seamless. For the informal sector, we have reached out to employers of labour at all spheres of endeavour, through sensitisation and engagement for them to see the need to bring in their staff alongside their families and wards into the health insurance. So the Health Insurance Scheme is available to all strata of society.
Robust Benefits Package:
The Insurance Scheme was designed in such a way that it is responsive and during the actual analysis that took place in 2017, one of the things we did was to make financial projections and if you look at our premiums, compared to other states, you’ll find that Edo State probably has the most robust benefit package. This has come to the fore in several national engagements where even other states wonder how we’re able to cope with the robust nature of our benefits package, and the reason we can do that is that at the actual studies in 2017 towards 2019, we did financial projections and accounted for many of these economic vagaries which we are seeing today. So a lot of facilities now are enjoying the benefits.
One of the things we have also done is the establishment of a pharmaceutical unit, quality control unit and a marketing unit that constantly has their ears on the ground regarding inflationary measures, cost of drugs, cost of medical personnel, and so on. So all these things are taken into cognisance and when we need to make adjustments, adjustments are made readily.
EDOHIS is the only Health Insurance Scheme in this country that has adjusted benefits and tariffs for the pricing of drugs and services over three times this year alone because we are responsive to not just the enrollees’ needs but the facilities as well. Now, there are co-payments made on the scheme for drugs and investigations. Enrollees are to pay 10% of the total cost for drugs and investigations. So I do not know if that is what some persons might have alluded to as out-of-pocket payment.
Essentially, what we do to avoid burnout and abuse of the system, is to ask enrollees to pay a token of 10% because we noted that if you make it completely free, a lot of people will just go there incessantly, even without complaints because they feel it is free money. So the 10% is just a deterrent and it is only for drugs and investigations. For procedures and consultations with doctors, they are free without any payment whatsoever.
The brain drain of medical practitioners has been a challenge for us but because we are also very dynamic and responsive, one of the things we have done through our clinical governance structure is to firstly increase the number of facilities available to the enrollees of the scheme. So it means that over a particular area, we have as many accredited facilities that meet the minimum standards, and so that increases our options. We have also done regular training of health trainees and personnel to be able to meet the minimum standards and benchmarks and because we collaborate with a lot of these facilities, we can say that based on insurance we can encourage a dermatologist in one facility to see a patient in another facility.
The formal sector plan which is essentially the family plan caters to the principal (the staff, who is an employee or appointee of the state government), his spouse and four children under the age of 18. So it means that under the formal sector plan, every civil servant has six slots. The reason it is designed like this is because it is expected that by the time you are 18 and above, you can now logically purchase an informal sector plan which is an individual plan.
As we speak, there is currently an engagement taking place between the Office of the Head of Service and Insurance to see ways and means of extending this health coverage beyond active service. There are several proposals currently on the table and I’m sure that as soon as it is practicable, once we get the approval, then we can start the orientation. Some persons have suggested that those who are a few years from retirement might pay a little more premiums to cover them, others are willing to continue paying even after retirement. Still, all these have to be finalised at the level of the Head of Service.
Data is key for us because all our decisions are based on data-driven evidence. One of the things we do monthly is having engagements with the Ministry of Health where we share and discuss data and one of the things we have seen is that in consonance with the national database, Malaria remains the most prevalent condition. We know that what most people refer to as Typhoid is the second most prevalent condition but they are closely followed by hypertensive conditions. We have seen that a lot of citizens are coming down with some other chronic conditions like diabetes. We have also seen an upsurge in peptic ulcer diseases. We can attribute this to the increased stress in society at this time.
One of the things we designed at the outset of the scheme was to have what we call add-ons. We decided that it wasn’t just enough to design a scheme that responds only to ailments and conditions, so for us, curative medicine was not our only objective. We are also focused on preventive and functional medicine and if you look at the paradigm shift from curative, rehabilitative medicine to preventive medicine, you’ll see that one of the things we’ve also drawn up are outreaches and screening programmes.
So what we do at tertiary institutions is drug screening and medical outreaches. So through our facilities that are close to these institutions, we have regular engagements with them, carry out outreaches and try and encourage them to partake in physical activities to prevent some of the chronic conditions that they may be susceptible to otherwise.
At Ambrose Alli University for example, we got someone from Irua Teaching Hospital to do a screening on students who volunteered by donating blood samples to determine if there were any recreational drugs and interestingly, we found that an appreciable number of them had some traces of recreational drugs in their system. So, that now formed the basis for us to engage the authorities and state, that as it stands, there is a need for us to increase the vigilance, and sensitisation among those groups of persons. We want to start with the Student Union Government (SUG) and the parliament to see how we can have campaigns that are sponsored by the Insurance and see how we can get the youths to desist from these activities.
Growing Local Pharmaceutical Business:
Insurance works with generic drugs for two reasons. One, for those who have a medical background, they will tell you one thing. All through medical training we were not taught to use Lonart or Amatem. There’s nothing like that; those are brand names. What we were taught were the constituents. That is what Insurance promotes. What we try to do is ensure that the facilities can procure qualitative and efficacious drugs because unfortunately in society today, there are a lot of fake drugs that have percentages of constituency below the standard percentages and that means that these drugs are not efficacious and unfortunately, for the antibiotics, it causes a lot of resistance because you are trying to treat a bacterial infection, and it requires 50% of a certain constituent and you’re giving the patient 10%.
Because the constituent is not enough to kill the bacteria, the bacteria then begin to build resistance to that particular drug. So what we did is that we have pharmacies in our Insurance Commission that carry out procurement training and did a tour of the facilities to let them know where to get the right drugs because we noted that before the Insurance Scheme, some facilities were trying to cut corners. They know that even among generic drugs, there are grades of drugs. There are drugs they bring in from downtown Onitsha and Lagos, as well as some other trusted sources, but because some of them want to make a profit, they will go for the lowest drugs so that they can try to make the most profit.
However, what we have tried to do is to stop the tide, to ensure that now we can monitor. We have gone as far as collaborating with the University of Benin Teaching Hospital (UBTH), where we do quality analysis. So for any facility where enrollees have complained incessantly about ineffective drugs, we will do a quality assay of that particular drug to determine the percentage of the constituents in that drug, to see if that is the reason why the drugs are ineffective. We found that especially for anti-malaria, some of the facilities are already used to getting drugs with very low constituent percentages and we will try to reduce that through our pharmacovigilance protocol.
So what we will do is that if an enrollee has a complaint about the drug being ineffective or producing an adverse reaction, we have a pharmacovigilance form in which they can fill out the details of the facility and we can follow up to ensure that we can stop the tide of patronising and administering ineffective and fake drugs.